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Medical Records
General Summary
A nonexempt position responsible for performing a variety of clerical duties to assist physicians, patients and clinical service managers.
Duties and Responsibilities
- Maintain Patient Medical Records in a confidential setting.
- Retrieve and distribute medical records, loose notes and reports in accordance with established priorities and procedures.
- Sort, file and collate a variety of medical records i.e. laboratory reports, clinic notes, etc in appropriate sequence and in accordance with established procedures.
- File and retrieve medical records with established color-coded terminal digit filing system.
- Research lost or missing records.
- Sort records request according to priorities and provide routine information of a general nature such as record number, admission and discharge dates and record location to authorized requestors.
- Generate new patient medical records as needed.
- Data entry of medical records.
- Purge files and separate according to needed material (make inactive file for old data).
- Pick up and deliver patient medical records from clinics, hospitals or other designated facilities as scheduled or prescribed.
- Review charts and make needed corrections.
- Mail medical records as requested.
- Assist with patient calls.
- Confirm patient appointments if needed.
- Maintain confidentially of all client/doctor related information.
- Perform other related duties as assigned by the supervisor or doctors.
Qualifications
EDUCATION AND EXPERIENCE
Minimum requirements
- High school diploma or General Equivalency Diploma (GED).
- Must have a valid driver's licenses and reliable transportation.
- Must have COVID Vaccine.
Performance Requirements
Knowledge
- Knowledge of basic medical terminology and office procedures.
- Knowledge of grammar, spelling and punctuation to type from draft, copy and review and edit reports and correspondence.
- Knowledge of basic arithmetic to make calculations, balance and reconcile figures and make changes accurately.
- Knowledge of computerized scheduling systems.
- Knowledge of medical practice protocols related to scheduling appointments.
- Knowledge of legal and ethical considerations related to patient information.
- Knowledge of customer service principles and techniques.
Skills
- Skill in operating office equipment.
- Skill in using computer and medical records software.
- Skills in organizational matters, including time management, prioritization, multitasking and problem solving.
- Skill in putting information in preferred medical record system, meeting clinic standards.
- Skill in dealing with masses of information in organized manner.
- Skill in communicating effectively with physicians/clinicians about scheduling preferences.
- Skill in generating reports from EMR as needed.
Abilities
- Ability to effectively communicate, read, understand and follow oral and written instructions.
- Ability to establish and maintain effective working relationships with patients, physicians, other clinical staff and the public.
- Ability to multitask effectively, dealing with phone calls, patients, staff and others calmly and pleasantly in all circumstances.
- Ability to analyze situations and respond appropriately.
- Ability to analyze medical records for completeness and accuracy, paying attention to detail.
